Question

At 64, Dr. Shaefer has been an internist for more than 30 years. He entered practice at the end of what has since been termed the "golden age" of medicine, before DRGs and managed care, when physicians made treatment decisions and carried them through unchallenged by third parties. After completing his residency, he joined a small group practice in the same city. The group practice has since grown to more than 20 physicians. Along the way, Dr. Shaefer was able to join the faculty at a local medical school as a clinical instructor. The position forced him to stay current with developments in general internal medicine and exposed him to new generations of students with diverse backgrounds and ideas. He was a conscientious teacher, committed to evidence-based medicine, and a caring practitioner, treating the person, not the disease.

Dr. Shaefer's children are well beyond college (one is now a physician, too) and have children of their own. Dr. Shaefer wants to spend more time with his family and has thought about retiring but wants to continue caring for patients in a less demanding environment. In reflecting on his career, he finds that practicing medicine is not as rewarding as it once was: it seems to be more about rushing patients in and out the door, securing pre-certifications, begging insurers to reconsider their reimbursement denials, explaining why the pill someone saw advertised on television is not really a magic bullet, and filling out paperwork—endless paperwork.

Dr. Shaefer is the first in his office to decide he is going to change how he practices. He is going to form a retainer practice, and reduce his patient panel from 3000 to 600. Over the next 6 months, he will write to all of his patients to explain that he is transforming his practice in order to provide enhanced patient care, and to invite those who are willing to pay an annual fee of $2000 to remain as his patients. Patients who join the "retainer practice," as it is called, will still be reimbursed by their insurance plans for those medical services that the plan covers. But insurance will not reimburse the "extra" services Dr. Shaefer would like to perform, accompanying patients to appointments with specialists, for example, providing more preventive care, and forming closer relationships with patients than he has been able to do of late. He wishes he could provide all his patients this same level of care, but he cannot. He will assist those who do not join the retainer practice in finding new physicians. Dr. Shafer has talked to his colleagues to ensure that they can take on those who do not join his new practice.

As he sees it, there are personal and professional reasons for undertaking this controversial change. He's getting older, he's done his share of pro bono work, and has contributed to educating the next generation of physicians. Some patients won't like the change, but they would have had to find another doctor had he retired. Through their choice to stay in his practice, those who pay will have validated his decision.

What is the bioethics issue(s) in this case? What would you advise Dr. Shaefer to do?

Answer 1

Note: This response is in UK English, please paste the response to MS Word and you should be able to spot discrepancies easily. You may elaborate the answer based on personal views or your classwork if necessary.

(Answer) The bioethics issue pertaining to the doctor himself, in this case, is that he would have to reject a few patients to bring the number down from 3000 to 600. Although he is getting old and is justified in his own way to be less encumbered, the basis upon which he retains certain patients and lets other go could pose an issue.

There might be a decent number of patients who would rely on his knowledge of their history in order to get cured. Other doctors might be helpful but would rely on the knowledge that only a family physician is likely to have.

In order to overcome this bioethics issue, the doctor should make organised files for each patient that he will let go to other doctors. This would be helpful for other doctors to continue any treatment or help with future differentials if necessary. The files should have medical records, test and scans, past medication, hereditary issues and other information that will be helpful for the patient in the future.